NHCX Overview

Overview

NHCX (National Health Claims Exchange) is the standard platform for exchanging claims and pre-authorization between healthcare providers (hospitals) and payers (insurers / government schemes such as PMJAY). Instead of each hospital talking to each insurer directly, a hospital sends standard FHIR-based bundles to NHCX, which routes them to the correct payer.

Within the system, the NHCX module lets you:

Check a patient's coverage and eligibility against a payer.
Submit pre-authorization and claim requests.
Cancel a pre-authorization.
Reprocess an erroneous or partially-paid claim.
Respond to payer communications (queries, payment notices).
Capture biometric verification (fingerprint / iris / face auth) required for admission and discharge.

Claim lifecycle

A typical NHCX workflow moves through these stages:

Eligibility check — confirm the patient's policy, coverage, and benefits.
Pre-authorization — get approval for the planned treatment.
Admission / treatment — biometric capture at admission, then at discharge.
Claim — submit the final claim for reimbursement.
Payment / communication — track payment notices and respond to queries.

Prerequisites

Before any NHCX workflow can run, the following must be in place:

Provider onboarding — the hospital must be registered as an NHCX participant with an active participant code (see NHCX Participant ID Generation).
HFR ID — a valid ABDM Health Facility Registry ID for the organization.
Payer discovery — the payers you work with must be discoverable/registered on the exchange.
Patient ABHA — patients need an ABHA number (and, for biometric flows, Aadhaar-linked mobile).

Key concepts

Term	Meaning
Participant code	Unique code identifying a provider or payer on NHCX (production codes end in `@hcx`).
Subscriber	The policy holder.
Beneficiary	The person receiving treatment (may be the same as, or different from, the subscriber).
Pre-auth	Prior approval for a treatment before it is carried out.
Workflow	A sequence of NHCX steps for one patient and payer, shown together on the patient's NHCX page.
Enhancement	Adding to an already-submitted pre-authorization (e.g., extra procedures).

Where everything lives

Task	Doc
Register as an NHCX participant	NHCX Participant ID Generation
Check a patient's coverage	Check Eligibility Coverage
Submit a claim	NHCX Claim
Newborn claims (parent + birth certificate)	NHCX Newborn Claim
Cancel a pre-authorization	Cancel Pre-authorization
Reprocess a claim	Reprocess Claim
Respond to payer queries	NHCX Communication
Biometric verification	NHCX Biometric
Understand the patient timeline	NHCX Patient Dashboard

FAQ

Q: Is NHCX the same as ABDM? A: No. ABDM is the broader Ayushman Bharat Digital Mission (health IDs, health records, linking). NHCX is the claims exchange that runs on top of it and uses ABHA numbers for patient identity.

Q: Who uses the NHCX module? A: Hospital admins and front-desk/billing staff who process claims and pre-authorization for patients with covered policies.

Q: What schemes does it support? A: It is payer-agnostic. PMJAY is a common scheme, but any payer registered on NHCX can be used.